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33: ENT & Oral Emergencies

IMMEDIATE MANAGEMENT OF LIFE-THREATENING DISORDERS

OBSTRUCTION

Acute obstruction within the nasal and oropharyngeal region is a seconds-to-minutes emergency. Rapid assessment is imperative to evaluate the degree and level of obstruction, and plans for intervention must be determined concomitantly. Severe obstruction can be caused by foreign objects, swelling secondary to trauma or infection, masses, and burns. History and examination are usually revealing; a high degree of suspicion should be maintained for foreign body in the context of severe, abrupt symptoms in the absence of other historical clues.

CLINICAL FINDINGS

History

Acute onset of signs and symptoms of respiratory distress is common; the insidious change of a subacute process can create equally serious management problems, although clues from the historical progression can guide evaluation and management. Maintain a high degree of suspicion for foreign body presence and do not discount the parents’ concern of foreign body, as this may be an important diagnostic key. Determine the chronology of symptom onset and suspected site (right nare, mouth, in the throat). Did the child admit to inserting or ingesting a foreign object? Was a specific event witnessed? Is the child making an effort to clear an obstruction (coughing or retching)? Is the child having noisy respiration with cry or exertion, and/or at rest? Has there been any color change, apnea, or inability to talk or cry? Have treatments or interventions been attempted prior to arrival that may have improved or possibly worsened the condition? Determine an accurate immunization history, if there has been an antecedent illness or fever, and whether this illness has been slowly progressive or of abrupt onset with rapid change.

Recent history of a traumatic injury, burn, or caustic ingestion can refine the differential diagnosis. Situations may present with similar symptoms of respiratory distress and airway compromise. Management of maxillofacial and neck traumatic injuries is discussed in Chapter 24. See Chapter 9 for a discussion of airway emergencies.

Physical Examination

Is the child in distress currently? Do not delay airway protection and supportive interventions for the sake of a detailed history and examination. If possible, have the patient report the history or describe symptoms. This provides the physician with opportunity to evaluate quality and limitation of phonation.

Does the child appear toxic? Depressed mental status, cyanosis, and poor respiratory effort are ominous signs. Recognize tachypnea, increased work of breathing, stridor, and other upper airway noises, and the position the child spontaneously assumes. Specific history of trauma may not be available; evaluate for burns, lacerations, punctures, or swelling that might indicate an unwitnessed injury. Examine the external head and neck structures for swelling, erythema, limitation in range of motion, and frank meningismus. If the condition permits, visually inspect the nares and oropharynx and note tolerance of secretions, signs of unilateral versus diffuse edema, erythema, purulent discharge, ...